Medical Procedure Costs

51285007997

LOESTRIN 21 1-20 TABLET

Prescription Drug - Generic

$1

—

51285008297

LOESTRIN 21 1.5-30 TABLET

Prescription Drug - Generic

$1

—

51285008498

LOESTRIN FE 1.5-30 TABLET

Prescription Drug - Brand

$3

—

51285008787

SEASONIQUE 0.15-0.03-0.01 TAB

Prescription Drug - Brand

$5

—

51285009287

LOSEASONIQUE TABLET

Prescription Drug - Brand

$3

—

51285010088

TAKE ACTION 1.5 MG TABLET

Prescription Drug - Generic

$9

—

51285010388

AFTERA 1.5 MG TABLET

Prescription Drug - Generic

$9

—

51285012058

MIRCETTE 28 DAY TABLET

Prescription Drug - Brand

$3

—

51285012570

LOESTRIN FE 1-20 TABLET

Prescription Drug - Brand

$8

—

51285027501

REVIA 50 MG TABLET

Prescription Drug - Generic

$1

—

51285036601

TREXALL 5 MG TABLET

Prescription Drug - Brand

$24

—

51285036801

TREXALL 10 MG TABLET

Prescription Drug - Brand

$48

—

51285040602

ENJUVIA 0.3 MG TABLET

Prescription Drug - Brand

$2

—

51285040702

ENJUVIA 0.45 MG TABLET

Prescription Drug - Brand

$2

—

51285040802

ENJUVIA 0.625 MG TABLET

Prescription Drug - Brand

$2

—

51285040902

ENJUVIA 0.9 MG TABLET

Prescription Drug - Brand

$2

—

51285041002

ENJUVIA 1.25 MG TABLET

Prescription Drug - Brand

$2

—

51285043165

QUARTETTE TABLET

Prescription Drug - Brand

$4

—

51285044102

CENESTIN 0.3 MG TABLET

Prescription Drug - Brand

$4

—

51500

Removal of bladder cyst

Surgery - Urinary

$580

—

51520

Removal of bladder lesion

Surgery - Urinary

$544

—

51525

Removal of bladder lesion

Surgery - Urinary

$773

—

51525683104

TRILYTE WITH FLAVOR PACKETS

Prescription Drug - Generic

$0

—

51530

Removal of bladder lesion

Surgery - Urinary

$696

—

51535

Repair of ureter lesion

Surgery - Urinary

$704

—

51550

Partial removal of bladder

Surgery - Urinary

$871

—

51555

Partial removal of bladder

Surgery - Urinary

$1,129

—

51565

Revise bladder & ureter(s)

Surgery - Urinary

$1,151

—

51570

Removal of bladder

Surgery - Urinary

$1,304

—

51575

Removal of bladder & nodes

Surgery - Urinary

$1,609

—

51580

Remove bladder/revise tract

Surgery - Urinary

$1,683

—

51585

Removal of bladder & nodes

Surgery - Urinary

$1,868

—

51590

Remove bladder/revise tract

Surgery - Urinary

$1,712

—

51595

Remove bladder/revise tract

Surgery - Urinary

$1,935

—

51596

Remove bladder/create pouch

Surgery - Urinary

$2,088

—

51597

Removal of pelvic structures

Surgery - Urinary

$2,040

—

51600

Injection for bladder x-ray

Surgery - Urinary

$37

—

51605

Preparation for bladder xray

Surgery - Urinary

$35

—

51610

Injection for bladder x-ray

Surgery - Urinary

$58

—

51645073110

CALCIUM 600 + VIT D 200 TABLET

Prescription Drug - Generic

$0

—

51645074010

DAILY VITAMIN FORMULA TABLET

Prescription Drug - Generic

$0

—

51645075010

DOCUSATE SODIUM 100 MG TAB

Prescription Drug - Generic

$0

—

51645085099

SENNA PLUS TABLET

Prescription Drug - Generic

$0

—

51645087006

SIMETHICONE 125 MG TAB CHEW

Prescription Drug - Generic

$0

—

51645090901

VITAMIN B-6 50 MG TABLET

Prescription Drug - Generic

$0

—

51645091401

VITAMIN B-12 1,000 MCG TABLET

Prescription Drug - Generic

$0

—

51660003531

ACID CONTROLLER 10 MG TABLET

Prescription Drug - Generic

$0

—

51660011231

CHILD LORATADINE 5 MG TAB CHEW

Prescription Drug - Generic

$1

—

51660012786

NORLYROC 0.35 MG TABLET

Prescription Drug - Generic

$0

—

51660033350

ARTHRITIS PAIN ER 650 MG CAPLT

Prescription Drug - Generic

$0

—

My Cost List